Guidelines for the Development of a Service Plan for Eating Disorders within Your Local Health District 1
Guidelines for Developing a Service Plan for Eating Disorders within your Local Health District Contents Page 1.1 The NSW Service Plan for People with Eating Disorders 2013-2018 3 1.2 Supports for the LHD to Develop the Plan 4 1.3 Scope of the Plan 4 1.4 Reasons for an Eating Disorders Service Plan 5 2.1 Role of the LHD 5 3.1 Brief Overview of the Service Spectrum for Eating Disorders 6 3.2 Access Points and Pathways to Address as Part of the Plan 7 3.3 Evidence Based Treatments for Eating Disorders and Workforce Development 8 3.4 Steps in Service Planning 9 4.1 Steps in Service Planning 10 Appendix A State-wide Governance Model Implementation of Service Plan 11 2
1.1 The NSW Service Plan for People with Eating Disorders 2013-2018 The NSW Service Plan for People with Eating Disorders 2013-2018 (the Service Plan) is committed to developing and improving the quality of eating disorder services and supporting better access to a range of evidence based and developmentally appropriate services for people with eating disorders. Following the release of the Service Plan, the NSW Government is committed to a comprehensive response that: Supports early and effective interventions to minimise distress to people with an emerging disorder, their families and carers Prevents the escalation of symptoms Promotes early recovery and Ensures access to specialist care. The Service Plan establishes a clear service goal for Local Health Districts (LHDs) to establish models of care that support a significant degree of clinical expertise and self-sufficiency. This includes a focus on strong governance, linkages and structures to support clinicians and service access across the state. In delivering the Service Plan, NSW Health recognises the significant contribution that primary and private health providers can make to the comprehensive management of these disorders. To build capacity at the local level (training the workforce to feel competent and skilled dealing with these illnesses, ensuring availability of a range of evidencebased therapies, streamlining access and pathways into hospital for the most severely ill, and supporting community evidence-based treatment for those needing it) will take time. Hence the implementation of the Service Plan will be a staged project. The first stage, through to 2015, includes the following priorities for LHDs: 1. Identifying current access points for service for people with eating disorders within your LHD; 2. Identifying major gaps in the service spectrum and workforce capacity to treat eating disorders within your LHD; 3. Developing a local Service Plan for eating disorders to guide current and planned service provision through to 2018 and beyond. 3
1.2 Supports for the LHD to Develop the Plan The NSW Ministry of Health has funded the Centre for Eating and Dieting Disorders (CEDD) to support roll-out of the plan across NSW. A request for support link on the CEDD website can be accessed by LHD staff at any time (www.cedd.org.au). A CEDD representative will be assigned to the LHD to support them through the process of implementing the plan. Guidelines and tools to assist them in completing the first stage of implementation are available on the website. While it is acknowledged that not all services for eating disorders will be provided by the LHD (e.g. prevention/very early intervention or tertiary specialist services), the plan identifies the LHD as the central hub for healthcare for its residents. The LHD will be supported further in its endeavours to provide access to the full range of service for people with eating disorders by the enhancement and expansion of the specialist tertiary hubs with a state-wide mandate for eating disorders for both children and adolescents, and adults. The Ministry of Health has enhanced state-wide adult inpatient services for eating disorders at Royal Prince Alfred Hospital (RPA) to provide a pathway to care for the most severely ill patients throughout NSW. Similarly, the child and adolescent state-wide specialist tertiary hub, delivered through Sydney Children s Hospital Network, has also been enhanced. LHDs as part of their Service Plan can articulate referral pathways to these Specialist Tertiary Hubs for treatment of severely ill patients that do not respond to treatment at the local level. Please see Appendix A for a pictorial representation of the supports and functions described above to support the development of LHD capacity in response to the Service Plan. 1.3 Scope of the Plan While all eating disorders are relevant to this plan, service development priorities are the four most common eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorders not otherwise specified (EDNOS) (or refer to as OSFED in DSM-V). Description of Types of Eating Disorders Eating disorders are a group of mental illnesses, which can adversely impact physical or mental health, growth and development. Eating disorders have very high rates of comorbidity and can lead to death. They cause distress, anxiety and burden to sufferers, their family, carers, and friends. Eating disorders are classified into four different types: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and OSFED - Other Specified Feeding or Eating Disorders. 4
1.4 Reasons for an Eating Disorders Service Plan Eating disorders cause significant morbidity and mortality Evidence-based treatments are available Recovery is possible Gaps exist in the range and effectiveness of eating disorders services e.g. regional differences in access to and delivery of services, particularly between urban and rural areas and between patients accessing private versus public services Practitioners knowledge, competence, and confidence can improve. 2.1 Role of the LHD Decisions about the level of funding available for eating disorders services and the provision of those services are the responsibility of each LHD. Each LHD is responsible for planning, developing, clinically prioritising, and delivering services to people with eating disorders. LHDs will decide how to implement the service model as part of their district and regional planning and prioritisation processes, and will take into account the need for further workforce development. The Ministry of Health anticipates that LHDs will use this document, collectively and individually, to guide their decisions about improvements to eating disorders services. LHDs will be required to produce a document to demonstrate how they intend to implement the key directions of this guide by the end of 2015, outlining their plans for the development of access points, pathways to care, workforce capacity building and eating disorder treatments available within the local LHD, as well as pathways to specialist tertiary services outside of the LHD for severely ill patients who fail to respond to local options. 5
3.1 Brief Overview of the Service Spectrum for Eating Disorders A Range of Services for Eating Disorders The service spectrum triangle, as presented in the Service Plan, can be used as a guideline to think about what services residents of your LHD with an eating disorder will need access to. Refer to Figure 1 below. While it is acknowledged that the LHD will not be responsible for the provision of services at every level of the service spectrum, the plan identifies the LHD as the central hub for healthcare for its residents. As part of the Service Plan, every LHD will be required to provide or provide pathways to the levels of service within the service spectrum. This approach assumes that treatment should match patient need, with the most complex and severe conditions being treated by the most specialised services and cases with less severe of complex presentation being managed locally in community based services wherever possible. According to this model, the less severe conditions (which are more common) should be treated at the primary care level, whereas specialist mental health, and health services should treat moderate to severe disorders, and tertiary level specialist care focus on the most severe conditions. 6
The first level is Generalist Health/Mental Health Community Interventions, represented by general practitioners, Medicare Locals, community mental health services, and NGO s. The next is a more specialised level of care including specialist day programs and community or outpatient clinics, as well as private specialist psychiatrists, psychologists, and dietitian treatment and planning, who in many cases form an integral part of the treatment team in eating disorders. The third level is local hospital interventions. This includes local psychiatric or medical beds, and consultation liaison mental health support, providing treatment for people with severe eating disorders needing medical stabilisation and nutritional rehabilitation. The fourth level is tertiary support that involves intensive multidisciplinary inpatient treatment, medical and weight stabilisation, and psychiatric care, suitable for people with the most severe eating disorders and complex presentations. Capacity within each level of the service spectrum does not necessitate the development of wholly new services. Much can be achieved through workforce development and capacity building within existing services to provide the requisite levels of expertise and knowledge of evidence based treatments to address eating disorders when they present. It will be local decision making within the LHD that determines which approach, models and strategies will work best within the district to begin the process of enhancing access, identifying pathways and providing care at each of these levels. 3.2 Access Points and Pathways to Address as Part of the Plan As part of the development of your local Service Plan for eating disorders the following pathways and access points are recommended for consideration. If your local Service Plan to 2018 addresses at minimum the following, it will go some way to providing access to a range of services across the spectrum for people with eating disorders: Developing Policy and Protocols for access through Emergency Departments for acutely medically unstable patients. Developing Policy and Protocols for access and admission criteria for both children and adolescents and adults to Mental Health ward/s within your LHD (see Guidelines for the Inpatient Management and MH-KIDs Toolkit on CEDD website for information about medical and psychiatric cut-offs, www.cedd.org.au) 7
Developing Policy and Protocols for access and admission criteria for both children and adolescents and adults to Paediatric/Medical wards within your LHD (see Guidelines for the Inpatient Management and MH-KIDs Toolkit on CEDD website for information about medical and psychiatric cut-offs, (www.cedd.org.au) Ensure that Policies and Protocols for triage and access for people with eating disorders via the State Mental Health Telephone Access Line (SMHTAL) are in place and meet the needs of your LHD. Developing Policy and Protocols for access and admission criteria for both children & adolescents and adults to Community Mental Health Teams (AMHS and CAMHS) within your LHD for treatment of an eating disorder. Developing Policy and Protocols regarding partnerships between Community Mental Health Teams (AMHS & CAMHS) and primary and private providers in the community (e.g. AMHS may act as case coordinator in a team where treatment delivered by GP and private psychologist and/or dietitian in the community) Developing Policy and Protocols for pathways from the LHD Mental Health, Paediatric and Medical Teams to specialist tertiary state-wide services for both children & adolescents and adults who are severely ill and unable to respond to local treatments. Developing Policy and protocols for the transition of patients with eating disorders from one sector of health to another (e.g. from private or primary to public), within public mental health services (e.g. from C&A to adult services) or within health services (e.g. from Mental Health or Medical Ward back to the Community Mental Health Team). 3.3 Evidence Based Treatments for Eating Disorders and Workforce Development In addition to developing policies and protocols for access for people with eating disorders to a range of existing services across the LHD, the LHD may identify the need to develop a local treatment hub for eating disorders. If so this part of the planning process will likely involve the following two aspects: (a) Selecting an Evidence Based Treatment to establish at the local level: 8
The CEDD website (ww.cedd.org.au) contains information, and resources on the evidence based treatments currently available for eating disorders for you to consider implementing at the local level. A CEDD member will be available to your LHD as a member of the working party and can provide guidance and information regarding different modalities of care for this patient group, up to date findings on evidence based treatments, and how to best match a model to the needs presenting in your community. (b) Workforce development to train local clinicians in evidence based therapies: Through the CEDD website you can gain access to the Online Learning Program in Eating Disorders (Eating Disorder Treatment Essentials: Detecting and managing eating disorders for the health professional) for staff within the LHD. This program has 5 modules providing core competency training for health professionals working with patients with an eating disorder. The website also has other online learning tools for evidence based practise. Your CEDD representative will work with your working party and other stakeholders to plan a tailored education and training program for the LHD to build the capacity of the local workforce to provide care for and where necessary evidence based treatments for eating disorders. 3.4 Steps in Service Planning The following steps are suggested as a guide to commence, manage, and complete the development of an Eating Disorders Service Plan: In short, Service Planning usually involves the following steps: Process: (a) Identify an appropriately qualified LHD staff member to act as lead officer for the Eating Disorders Service Plan and review administrative support required to support the process. (b) Develop a stakeholder list for inclusion in work related to the plan and for consultation ensuring broad representation of clinicians, service providers and consumer and carer representatives (c) Design a governance structure and process to oversee the development of the plan. Consideration should be given to including representation from key eating disorder service providers, where they exist within your LHD, and also including 9
representation from the District Executive, the District Mental Health executive, Senior Medical representation, Paediatric, Community Health, and Emergency Departments, consumers and carers. The process of identification of working party members and key stakeholders within your LHD is pivotal to the success of the project and will require discussion, thought and consultation at the local level. Specific consideration at this stage as to the design model that will be used is advised. For example, co-design models that support clinical, consumer and carer expertise in service design. 4.1 Steps in Service Planning Develop up a version of the desired service model using available epidemiological, demographic, service model and service utilisation data, including where available public and private funded activity. A representative from The Centre for Eating and Dieting Disorders (CEDD) is available to be invited to join the working party to represent the state-wide perspective and Mental Health Drug and Alcohol Office (MHDAO), to provide broad guidance and access to tools and supports and contribute knowledge about up-to-date evidence-based practice and service design. (a) Develop a vision for the eating disorder service that includes service elements, pathways and service volumes. (b) Conduct a gap analysis (c) Identity priorities for Service Development and develop an Implementation Plan. (d) Consider the broad dimensions of activity that may require dedicated timelimited work groups to support implementation: for example, clinical governance (consider policies and procedures; evidence-based practices); resources (consider opportunities for efficiencies and/or redistribution); workforce development; infrastructure support (for example, data requirements). (e) Consider the evaluation plan for the service and the significant mile-stones that you will want to report on and celebrate successes! 10
Appendix A Building Capacity of NSW Health System to Deliver Services for People with Eating Disorders NSW Service Plan for People with Eating Disorders Implementation Steering Committee Stewardship Planning Monitoring Coordination & Collaboration Statewide Centre for Eating and Dieting Disorders (CEDD) Coordination & Collaboration Eating Disorders Service Coordinator/ Lead Eating Disorders Service Coordinator Eating Disorders Service Coordinator Eating Disorders Service Coordinator Child & Adolescent Mental Health Clinical Hub of Excellence Sydney Children s Hospital Network Leadership Strategy Service Development & Workforce Development Strategy and Implementation Clinical Practice Advisory & Support Information & Resources Adult Mental Health Clinical Hub of Excellence Royal Prince Alfred Hospital Tertiary inpatient treatment Specialist Outpatient Clinics & Day Programs Specialist Consultation for Complex cases Specialist Training especially for Rural LHDs Tertiary inpatient treatment Specialist Outpatient Clinics & Day Programs Specialist Consultation for Complex cases Specialist Training especially for Rural LHDs Local Health Districts & Specialty Networks Local governance structure to develop and implement local service plan including an identified leader and working party Local mental health assessment and treatment of people with Eating Disorders, including emergency department consultation, inpatient, outpatient & community mental health services Workforce recruitment and development Key Partnerships NSW Kids & Family Medicare Locals Private Providers Butterfly Foundation/ NEDC NSW CAG Emergency Departments NGO s Promotion, Prevention and Early Recognition Primary and secondary Treatment 11